Health, Dental and Travel Insurance by Victor

OHIP Overview

If you are a resident of Ontario, OHIP covers residents for medical services in hospitals, healthcare clinics and doctor’s offices. Benefits include diagnostics, surgeries, and services provided by a licensed physician that are considered medically necessary.

OHIP also covers emergency medical services for travel which is limited. Out of province coverage is available up to the same limit OHIP pays in Ontario which is currently a maximum of $400 a day for in hospital care, and $50 for a doctor’s visit. We all know that if you have a medical emergency in another country the cost of care can be extremely high, often in the thousands of dollars for one medical event. OHIP recommends that you purchase private travel insurance to assist with the cost of medical emergencies when travelling.

After your 65th birthday, OHIP offers some additional benefits.

• The Ontario Drug Benefit (ODB) covers about 5,000 of the over 10,000 prescription drugs prescribed by doctors today. However, you pay a $100 annual deductible, which means that you pay for the first $100 of your prescriptions every year beginning every August. You also pay for the dispensing fee on your prescriptions up $6.11 per prescription filled.
• Some people believe that the ODB will cover all of their prescription needs in retirement, however, we know at Victor that 48% of all of our health care claims are for prescription drugs alone.
• MROO health care covers prescription drugs after age 50, the $100 ODB deductible, and dispensing fees at 90% at all ages.
• Our $2,400 annual drug maximum in 2023 meets the needs of the majority of MROO policyholders and we review it annually to keep pace with inflation in drug costs.

OHIP pays for one eye exam every 12 months until September 1, 2023 when this benefit will change to one eye exam every 18 months. OHIP also pays for physiotherapy services after hospitalization.

OHIP Limitations and Issues 

OHIP benefits are limited in scope and can change at any time. Government budgeting for healthcare only goes so far, each year, and priorities can change. For example, funding long-term care, staffing for doctors, and nursing care. Over the years OHIP has stopped offering some benefits that you might expect OHIP to cover. OHIP has delisted chiropractic services and PSA tests and has limited physiotherapy services and eye exams to residents over 65 and under 18 only.

Suspending OHIP Benefits in the Past:

• In 2019, emergency medical travel coverage while outside of Ontario wad delisted (reinstated 2020).This action was challenged in court and the Superior Court of Justice ruled that the government's move to eliminate the out-of-country travel program violated the portability pillar of the Canada Health Act and coverage has been reinstated. Under law you must be able to take the same OHIP benefits you have at home in Ontario, with you wherever you are in the world.
• In the fall of 2021 vision care services were unavailable to persons over age 65 for a limited time when optometrists took OHIP to task and demanded more for the OHIP services they were providing. In March 2023, the Ontario Association of Optometrists came to a funding agreement with OHIP that will increase payment to them, however, that agreement included a reduction in service. Beginning September 1, 2023 there will be a change in coverage for residents over age 65 and eye exams will be offered every 18 months instead of every 12 months – Implementing the New Optometry Services Agreement.
• It’s important to have a health insurance plan that is updated annually to keep pace with OHIP changes.
• When OHIP delisted chiropractic services and PSA testing MROO added this coverage under our health plan. We also offer physiotherapy benefits at all ages.

When is the Best Time to Purchase Insurance?

As soon as you retire? Not necessarily but rules for eligibility are important when thinking about your purchase. When you no longer have coverage under an employer group insurance plan through your employer or your spouse.

If you are worried about the cost of paying for the benefits and services that were covered under your employer plan, you will want to purchase your own health Insurance plan to top up OHIP coverage. Choosing an effective date for your insurance plan that coincides with the termination date of your group plan maintains continuity in health care coverage.

Note: After retirement, when your employer insurance ends you may be able to get coverage under your spouse’s employer healthcare plan. If so, you don’t need two plans you can wait to purchase insurance when that health insurance plan ends.

Guaranteed acceptance at time of application: Keep in mind that most plans allow you to enroll without a medical within 60 days of losing your employer benefits. MROO actually has a 90-day window for guaranteed enrollment after losing coverage in any health insurance plan.

When paying medical bills that aren’t covered by OHIP become unmanageable. If you find your health, dental and travel medical expenses become more than you expected to pay on an ad hoc basis, you will want to consider private insurance. The cost is in the form of a monthly premium for a comprehensive benefit package, which is a predictable and more manageable expense.

Before you reach age 81. Most plans do not offer insurance beyond this age.

How do You Find the Right Insurance Plan? 

There are many private insurance plans available, with many different options. It can be overwhelming and take some research to find a plan the right plan.

Here are some things to consider when comparing plans:

1. Does the plan offer the benefits that are important to you?

2. Does the plan include the coverage you need?

3. Can I afford this plan now and throughout my retirement?

4. Can I keep my plan for life - and can my partner?

5. Where can I find a plan that’s right for me?

Does the plan offer benefits that are important to you? And does it include benefits I don’t need? This question is important because you don’t want to pay for benefits you won’t use. For example, you need health insurance but not travel insurance. There are two ways you can purchase private health insurance; an all-inclusive plan that bundles health, dental and travel in one plan, or plans are available on a standalone basis - you can purchase only the plans you want - separately.

Bundling has disadvantages:

You can’t cancel only one benefit: Even if you want all of the coverage now - the downside of a bundled plan is that you can’t terminate any portion of the plan if you find that you don’t need it as you get older. For example, if you stop travelling, and travel and health are combined, you have to keep your travel coverage even though you won’t use it – and you will have to pay for it. Keep in mind that when a plan is bundled, your premium dollars may be going towards funding the cost of benefits for others.

• We know from the MROO insurance plan that only 50% of our health policyholders also enroll in the dental plan, and only 50% of applicants take the annual travel option.
• You may be getting benefits that you don’t need, and you are paying for them. only 50% of applicants take the annual travel option
• MROO offers health, dental and travel in separate plans – dental and travel must be purchased at the same time as health insurance but either can be terminated at any time. (No re-enrollment option)
• Ease of purchase is important - You might also find it more convenient if you can get all of the insurance plans you need in one place. MROO offers a comprehensive retiree benefit program

Does the plan include the coverage I need?

The benefits you will find in a private health care plan, age 50+, will be similar to those you had with your employer plan, however, the maximum annual limits for each benefit are generally lower to keep costs down.

Most plans have similar coverage such as prescription drugs, hospital room, paraprofessional services such as chiropractic services or massage therapy, nursing care, medical equipment, vision care and ambulance services but they can vary in the amount of coverage offered. Consider just how much coverage you will use.

Some plans offer higher limits than you might need. For example: the MROO plan has an annual maximum of $2400 per person in 2023. Other plans may offer a higher prescription drug annual maximum, but we know from experience that only 5% of our policyholders will ever claim more than our current maximum. We design our benefits to meet the needs of the majority of our policyholders in any given year.

Health insurance plans have similar benefits, but there are some newer benefits available in the retiree marketplace that might be valuable to you and you will want to look for them. Mental health is something most plans are addressing in their benefits. This year MROO has added social worker to our psychologist benefit because those services are easier to access and more cost effective than a psychologist for our policyholders.

 Price is important. You will want to get the most value you can for your premium dollar.

 How About Virtual Healthcare?

Virtual health services have become very popular during COVID and this is a trend that we expect to continue. This is something to look for in a health care plan. If you have an insurance plan now or you are shopping for one, it should include the service for virtual health care. Most plans do now. It’s convenient and safe and you can avoid waiting rooms, travel and parking. You should know that physicians support virtual health care  and does not conflict with OHIP services in any way.

Here are some of the highlights of the Maple virtual health service that MROO offers:

Maple provides for quick access to communicate with a licensed physician 24/7 online, rather than in person. Other plans usually only have a nurse practitioner on call.

You can use the service anytime, and anywhere, even out of country (consultation only). We already know how expensive it is paying for medical services out of Canada. Depending on the severity of your medical emergency, you can use Maple to consult with a physician who is able to assess your condition before you consider a visit to a doctor or clinic – which may not be necessary.

Most Maple visits are for a quick consult and/or to renew a prescription.

And a special service offer by Maple is their centralized medical record keeping. Maple coordinates with your family physician so that your health care records are consolidated. This is helpful as we continue to need to advocate for our own health care needs.

Is the MROO Insurance Plan Competitive in the Marketplace for Seniors? What about future Pricing?

Plan premiums generally increase year over year due to inflation, claims experience and when benefits are enhanced. When researching plans, ask how much rates increased in the last 5-10 years to see the rate history and/or take a look at the average rate increase on the plans you want to purchase.

• MROO health and dental plans are reviewed annually and benefit enhancements are made almost every year. Some years we made several plan improvements. The average annual rate increase for health and dental insurance over the last 10 years has only been 1.8%.  

Age Banding – Plans that Go up in Price Every 5 years Because of Age 

Age is a big factor in determining health insurance premiums. Most plans price their insurance in five-year age bands, for example 60-65, so your insurance rates go up every five years after your birthday. You pay more for the same insurance as younger plan members due to age. This is problematic particularly if you are living on a limited income. Likely you will need health care more as you age and you shouldn’t have to pay more just to keep your insurance.  

• MROO does not have age banding. Everyone pays the same rate regardless of age – whether you are 50 or 90.
• Non-age banding is a more equitable rating structure and it provides plan members with a more stable and predictable expense meaning that you’re more likely able to maintain your insurance throughout your retirement because it’s easier to budget long term - and it’s more affordable.

Does the Plan have a Termination Date? 

Some plans end or limit coverage at a certain age or they do not offer all insurance coverage for life, for example dental and/or travel coverage. It is important to know that most insurance plans are only offered up to age 80 so if your insurance ends at that age you will not be able to get health insurance for the remainder of your life and when you need it most as you are aging. Some plans end benefits for spouses or family members when the eligible plan member dies. In other plans, if the policyholder passes away, coverage for the surviving spouse may only continue for a year or two. Lifetime coverage for retirees & spouses is very important and you should look for a plan that offers coverage for life.  

MROO offers benefits for life for you and your spouse.

What Kind of Insurance Plans Do You Offer and Where do I Find Them? 

1. Group plans are designed for employees and the employer is the group policy contract holder who determines what benefits are offered. The employees who have coverage can refer to their coverage in an insurance booklet. Eligibility is based on employment so employees usually lose their insurance benefits when they no longer work for the company or at a specific age such as 65 or 70. Some employers limit eligibility to full time workers only and not casual or part time staff.

2. Private health insurance plans can be purchased personally and they come in the form of an individual insurance plan or an affinity insurance plan. 

3. An affinity plan is a bit more like a group plan because it sponsored by a specific group, organization or association. Affinity Plans are available through insurance carriers who specialize in this insurance. Benefits are offered as a benefit of membership in an association and that association is the plan sponsor who promotes awareness of the plan to their members. The members of the association have an affinity to each other: such as university alumni, retired teachers, police or public service retirees. There are eligibility requirements to participate in these insurance plans to ensure the applicant is affiliated with the sponsoring association and there may be age or relationship restrictions such as spouse or family for enrollment and/or when benefits end.   With affinity plans, the policyholder is issued their own insurance policy and can cancel their insurance at any time. 

4. Individual plans are sold directly to consumer from the insurance company. You've seen them advertised on TV, you can google them, and they can be purchased from any leading insurance provider like Sun Life, Manulife and Green Shield.

Who Does What? (Insurance companies, advisors, claims, administration)

• Insurance companies take on the risk of insuring that your claims will be paid for the insurance you purchase. They offer insurance benefits that suit their business portfolio: for example life and health insurance or home and care insurance. The insurance company adjudicates and pays claims. When you have a claim dispute you must take it up with them.
• The plan sponsor is the employer or affinity group who offers the insurance to their employees, retirees or members. Sometimes enrollment is mandatory, as with employer group insurance, or it can be voluntary, such as with an affinity plan. Under an affinity plan the sponsor promotes the plan to those eligible for the insurance offered. and 
• There can be an advisor or insurance program manager who helps the employer or association find the right insurance provider and works with them to design the right insurance plan for their employees or members.
• Plan administration and enrollments are either managed by the insurance program manager, a third-party administrator (TPA), when the insurance product is purchased directly from them, or “off the self”.

• MROO has an insurance manager, Victor, who bring together preferred insurance solutions from multiple carriers, with comprehensive benefits, that are competitive in the market place. Plans are designed specifically for our member needs. Victor has a full-time client service team to respond to MROO members and policyholder questions and provide assistance with enrollment.

• OMERS supports MROO advocacy and services: Preparing to Retire (omers.com)

Peace of Mind – Enrollment

The bottom line is that you want a plan that will help to pay for the things that you need, as well as be there to help with unexpected costs. 

MROO’s insurance plan is slightly different from other plans for seniors:

Specifically designed for OMERS retirees 

Rates are not age or health related same rates for everyone in the same plan

Quick and easy online enrollment 24/7

You can apply for insurance anytime between ages 50 and 81

Once you are enrolled in any MROO plan you can keep it for life

When OHIP delists benefits MROO looks to add them to our plan

You and your spouse can enroll when you lose your employer benefits together or separately

And you and your spouse can keep your benefits for life